Platelet-rich plasma injections

for knee osteoarthritis

Interventional procedures guidance

Published: 23 January 2019
www.nice.org.uk/guidance/ipg637

Your responsibility
This guidance represents the view of NICE, arrived at after careful consideration of the
evidence available. When exercising their judgement, healthcare professionals are
expected to take this guidance fully into account. However, the guidance does not
override the individual responsibility of healthcare professionals to make decisions
appropriate to the circumstances of the individual patient, in consultation with the patient
and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the guidance, in their

local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
guidance should be interpreted in a way that would be inconsistent with compliance with
those duties.

Commissioners and providers have a responsibility to promote an environmentally

sustainable health and care system and should assess and reduce the environmental
impact of implementing NICE recommendations wherever possible.

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Platelet-rich plasma injections for knee osteoarthritis (IPG637)

This guidance replaces IPG491.

1 Recommendations
1.1 Current evidence on platelet-rich plasma injections for knee
osteoarthritis raises no major safety concerns. However, the evidence on
efficacy is limited in quality. Therefore, this procedure should only be
used with special arrangements for clinical governance, consent, and
audit or research.Find out what special arrangements mean on the NICE
interventional procedures guidance page.

1.2 Clinicians wishing to give platelet-rich plasma injections for knee

osteoarthritis should:

• Inform the clinical governance leads in their NHS trusts.

• Ensure that patients understand the procedure's safety and efficacy, as well as
any uncertainties about these. Provide them with clear information to support
shared decision making. In addition, the use of NICE's information for the public
on platelet-rich plasma injections for knee osteoarthritis is recommended.

• Audit and review clinical outcomes of all patients having platelet-rich plasma
injections for knee osteoarthritis, including details of the methods used to
prepare and administer the platelet-rich plasma injections. NICE has identified
relevant audit criteria and has developed NICE's interventional procedure
outcomes audit tool (which is for use at local discretion).

1.3 Further research should be in the form of randomised controlled trials

with medium- to long-term follow-up, including validated measures of
knee function and patient-reported outcomes.

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Platelet-rich plasma injections for knee osteoarthritis (IPG637)

2 The condition, current treatments and

procedure
The condition
2.1 Osteoarthritis of the knee is the result of progressive deterioration of the
articular cartilage and menisci of the joint, usually because of trauma,
and wear and tear. This leads to exposure of the bone surface.
Symptoms include pain, stiffness, swelling and difficulty walking.

Current treatments
2.2 Treatment depends on the severity of the symptoms. Conservative
treatments include analgesics and corticosteroid injections to relieve
pain and inflammation, and physiotherapy and prescribed exercise to
improve function and mobility. When symptoms are severe, surgery may
be indicated: options include upper tibial osteotomy and
unicompartmental or total knee replacement.

The procedure
2.3 Platelet-rich plasma is prepared by a clinician or a technician. Blood is
taken from the patient and centrifuged to obtain a concentrated
suspension of platelets in plasma. Different preparation methods may
affect the concentrations of platelets and the level of contamination with
red and white blood cells. Different agents such as calcium chloride or
thrombin may be added.

2.4 The platelet-rich plasma is injected into the joint space in the knee,
usually under ultrasound guidance. Platelets contain growth factors that
are thought to stimulate chondrocyte proliferation, leading to cartilage
repair. The aim is to relieve symptoms, potentially delaying the need for
joint replacement surgery. This guidance refers to the use of platelet-rich
plasma injections alone and not as part of a combination therapy.

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3 Committee considerations
The evidence
3.1 To inform the committee, NICE did a rapid review of the published
literature on the efficacy and safety of this procedure. This comprised a
comprehensive literature search and detailed review of the evidence
from 8 sources, which was discussed by the committee. The evidence
included 3 systematic reviews and 5 randomised controlled trials, and is
presented in table 2 of the interventional procedures overview. Other
relevant literature is in the appendix of the overview.

3.2 The specialist advisers and the committee considered the key efficacy
outcomes to be: reduction in pain and improvement in knee function
using validated scores, and quality of life.

3.3 The specialist advisers and the committee considered the key safety
outcomes to be: infection, bleeding, pain and inflammation.

3.4 Patient commentary was sought but none was received.

Committee comments
3.5 There are several different treatment protocols with different preparation
and administration methods, resulting in higher or lower concentrations
of platelets. Some protocols use plasma that has either low or high
concentrations of leukocytes (white blood cells).

3.6 This procedure is used for patients with early or mid-stage knee
osteoarthritis.

ISBN: 978-1-4731-3200-9

Endorsing organisation
This guidance has been endorsed by Healthcare Improvement Scotland.

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Accreditation

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